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Patients often give a family history of migraine Attacks may be triggered by emotional or physical stress, lack or excess of sleep, missed meals, specific foods (eg, chocolate), alcoholic beverages, menstruation, or use of oral contraceptives An uncommon variant is basilar artery migraine, in which blindness or visual disturbances throughout both visual fields are initially accompanied or followed by dysarthria, disequilibrium, tinnitus, and perioral and distal paresthesias and are sometimes followed by transient loss or impairment of consciousness or by a confusional state This, in turn, is followed by a throbbing (usually occipital) headache, often with nausea and vomiting In ophthalmoplegic migraine, lateralized pain often about the eye is accompanied by nausea, vomiting, and diplopia due to transient external ophthalmoplegia The ophthalmoplegia is due to third nerve palsy, sometimes with accompanying sixth nerve involvement, and may outlast the orbital pain by several days or even weeks The ophthalmic division of the fifth nerve has also been affected in some patients Ophthalmoplegic migraine is rare; more common causes of a painful ophthalmoplegia are internal carotid artery aneurysms and diabetes In rare instances, the neurologic or somatic disturbance accompanying typical migrainous headaches becomes the sole manifestation of an attack ( migraine equivalent ) Very rarely, the patient may be left with a permanent neurologic deficit following a migrainous attack
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Depression headaches are frequently worse on arising in the morning and may be accompanied by other symptoms of depression Headaches are occasionally the focus of a somatic delusional system Antidepressant drugs are often helpful, as may be psychiatric consultation
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Headache, usually pulsatile Nausea, vomiting, photophobia, and phonophobia are common accompaniments May be transient neurologic symptoms (commonly visual) preceding headache of classic migraine No preceding aura is common
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The pathophysiology of migraine probably relates to the neurotransmitter serotonin Headache may result from release of neuropeptides acting as neurotransmitters at trigeminal nerve branches, leading to an inflammatory process; another possible mechanism involves activation of the dorsal raphe nucleus Imaging studies have revealed changes in brainstem regions involved in sensory modulation, suggesting that migraine relates to a failure of normal sensory processing
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Treatment
Management of migraine consists of avoidance of any precipitating factors, together with prophylactic or symptomatic pharmacologic treatment if necessary
A Symptomatic Therapy
Clinical Findings
Classic migrainous headache is a lateralized throbbing headache that occurs episodically following its onset in adolescence or early adult life, although not all headaches that are throbbing in character are of migrainous origin Moreover, in many cases the headaches do not conform to this pattern, although their associated features and response to antimigrainous preparations nevertheless suggest that they have a similar basis In this broader sense, migrainous headaches may be lateralized or generalized, may be dull or throbbing, and are sometimes associated with anorexia, nausea, vomiting, photophobia, phonophobia, and blurring of vision They usually build up gradually and may last for several hours or longer They have been related to dilation and excessive pulsation of branches of the external carotid artery Focal disturbances of neurologic function may precede or accompany the headaches and have been attributed to constriction of branches of the internal carotid artery Visual disturbances occur quite commonly and may consist of field defects; of luminous visual hallucinations such as stars, sparks, unformed light flashes (photopsia), geometric patterns, or zigzags of light; or of some combination of field defects and luminous hallucinations (scintillating scotomas) Other focal disturbances such as aphasia or numbness, tingling, clumsiness, or weakness in a circumscribed distribution may also occur
During acute attacks, many patients find it helpful to rest in a quiet, darkened room until symptoms subside A simple analgesic (eg, aspirin, acetaminophen, ibuprofen, or naproxen) taken right away often provides relief, but treatment with extracranial vasoconstrictors or other drugs is sometimes necessary Cafergot, a combination of ergotamine tartrate (1 mg) and caffeine (100 mg), is often particularly helpful; one or two tablets are taken at the onset of headache or warning symptoms, followed by one tablet every 30 minutes, if necessary, up to six tablets per attack and ten tablets per week Because of impaired absorption or vomiting during acute attacks, oral medication sometimes fails to help Cafergot given rectally as suppositories (one-half to one suppository containing 2 mg of ergotamine) or dihydroergotamine mesylate (05 1 mg intravenously or 1 2 mg subcutaneously or intramuscularly) may be useful in such cases Alternatively, prochlorperazine administered rectally (25 mg suppository) or intravenously (10 mg) may be prescribed Ergotamine-containing preparations may affect the gravid uterus and thus should be avoided during pregnancy Sumatriptan, which has a high affinity for serotonin1 receptors, is a rapidly effective agent for aborting attacks when given subcutaneously by an autoinjection device It can also be taken in a nasal form, but absorption is limited, and an oral preparation is available Zolmitriptan, another selective serotonin1
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